WorkCover online system - Claim lodgement

Make a claim

To lodge a claim with us, please complete the form below.

We encourage workers and employers to complete this form together. That's because workers need to notify their employer when they are injured at work, and their employer will be contacted to discuss the claim.

If the form cannot be completed together, employers must ensure they have the worker's consent to lodge the claim on their behalf.

Alternatively you can lodge certain types of claims over the phone. These are:

Fatal claims
Urgent surgery is required / urgent surgery requests

Please call us on 1300 362 128 to lodge these types of claims.

* Mandatory field

Tell us who you are

* Who is registering the WorkCover claim?

* What is the claim for?

Worker's details

* Title

* First name

* Surname

Middle name

Previous first name

Previous surname

Previous middle name

* Date of birth e.g. 25 JUL 2014

* Gender

Mobile You must provide at least one contact number.
For claim lodgements, an SMS will be sent to the worker when a mobile number has been provided.

Work telephone

Home telephone

* Email A copy of the claim form and receipt number will be sent to this address.

Worker's residential address

* Is the address inside QLD?

Yes

Building

Street no.

* Street

* Street type

* Suburb/locality

* Postcode

* State/province

* Country

Different postal address?

Worker's postal address

Is the address inside QLD?

Yes

Building

Street no.

Street

Street type

Suburb/locality

Postcode

State/province

Country

Worker's bank details We pay claim and medical reimbursement payments by electronic funds transfer.

BSB e.g. 633000

Bank

Branch

Account name

Account number

Employer's details

* Trading name

Legal name

Business address

* Is the address inside QLD?

Yes

Building

Street no.

* Street

* Street type

* Suburb/locality

* Postcode

* State/province

* Country

* Work telephone

Mobile

Fax

Email A copy of the claim form and receipt number will be sent to this email address

WorkCover policy number

ABN

Please select the WorkCover industry classification for this claim

Worker's employment details

* Occupation

* Was the worker any of the following at the time of the injury?

* Please give details

* Did the injury happen

* Employers only - can you confirm that the event occurred at work, or on the worker's way to work, and that the worker suffered a work related injury as a result of that event?

Yes

* If no, provide relevant information to help us determine the claim

If the employer is not entitled to claim back all of the GST, what percentage can be claimed?

Worker's wage information

Payroll/reference number

Hours per week

Gross weekly rate of salary/wages (industrial instrument) An industrial instrument means certified industrial agreement including an award or EBA

* Has the employer excess been paid?

Yes

* Has the employer continued to pay the worker's salary or wages during the period of incapacity (in addition to the excess)?

Yes

Employer's bank details Provide employer's bank details for payment to be remibursed by electronic funds transfer

BSB e.g. 630000

Bank

Branch

Account name

Account number

Claim summary

The following is a summary of your claim lodgement. Please review and read the statements before you submit.

Worker

Name

Address , AUS

Email supplied No

Occupation

Description of injury/illness

Bodily location

When did the injury happen?

Address , AUS

How did the injury happen? e.g. lifting steel rods from the floor to a bench

Business / Employer

Trading name

Address , AUS

Email supplied No

Supporting documents

Attachments

Please upload any supporting documentation you may have such as medical certificates, receipts etc.

WorkCover privacy notice

WorkCover Queensland (WorkCover) is collecting your personal information under the provisions of the Workers' Compensation and Rehabilitation Act 2003 to assess your entitlement to compensation and manage your claim throughout its duration. WorkCover may give some of your information to your employer, the Workers' Compensation Regulator and relevant service providers for the purpose of payments, treatment, rehabilitation and return to work.

Your information will be treated in accordance with the Information Privacy Act 2009 and will not be given to any other person unless authorised or required by law. For more information on privacy, visit our website at www.worksafe.qld.gov.au/about/privacy/workcover-queensland-privacy/privacy-statement or call us on 1300 362 128.

Worker's statement

I acknowledge that it is an offence against the Workers' Compensation and Rehabilitation Act 2003 to make a statement that is false or misleading. The information I have provided is true and not misleading.

I agree to advise WorkCover Queensland if my circumstances change or if I become aware of any matter that would make the above information false or misleading. I will advise WorkCover Queensland if I undertake any employment (paid or unpaid), including self-employment, during my claim.

I authorise any doctor, health authority, allied health provider, rehabilitation provider, or other insurer to disclose to WorkCover Queensland and its agents any information about my medical history relevant to this claim.

I have read and understand the privacy notice.

* Worker agrees to the above statement

Employer's statement

This section does not need to be completed for a valid application to be made, however it may assist us to make a quicker claim decision if it is completed

I have read the information provided with this form. I acknowledge that it is an offence against the Workers' Compensation and Rehabilitation Act 2003 to make a statement that is false or misleading. The information that I have provided is true and not misleading.

I have read and understand the privacy notice.

* Employer agrees to the above statement